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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004132
Report Date: 11/18/2021
Date Signed: 11/18/2021 12:44:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ALL FIVE @ BELLE HAVEN (PS)FACILITY NUMBER:
414004132
ADMINISTRATOR:CAROL THOMSENFACILITY TYPE:
850
ADDRESS:415 IVY DRIVETELEPHONE:
(650) 387-8268
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:24CENSUS: 24DATE:
11/18/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Carol ThomsenTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Marie Rodriguez made an announced Case Management inspection. LPA met with Director Carol Thomsen and explained purpose of inspection. Licensee is requesting an increase of capacity to 40 children and a room addition of P16. Facility currently has a capacity of 24 children and uses room P15. Present at the facility were the Director, 6 teachers, and 24 children (preschool aged). Facility was inspected today for health and safety hazards and measured to calculate capacity.

LPA and Director toured room P16 for health and safety hazards. Classroom has an industrial fire alarm, a smoke and carbon monoxide detector, and a fully charged fire extinguisher. Classroom has a bathroom with two toilets and one sink. A second sink outside of the bathroom will be used for children's use. Classroom currently has appropriate chairs and tables for children along with cots on the side wall. There is a storage space for children's personal belongings. Children's toys and other equipment will be moved into the classroom once the current family program, Family Connections, has fully moved out of the room.

Total useable indoor area for room P16 measures at 925.19 sq ft divided by 35 sq ft equals 26 children. Applicant is requesting an increase of capacity for a total of 40 children for rooms P15 and P16. Current outdoor area used for children measures at 4,170.99 sq ft divided by 70 equals 55 children.

An initial fire clearance inspection was conducted on Tuesday, November 16, 2021. A follow up inspection will be conducted by Fire Inspector once room has been fully furnished.

LPA will approve the increase of capacity to 40 children and room addition of P16 once fire clearance has been granted by Fire Inspector.

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SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ALL FIVE @ BELLE HAVEN (PS)
FACILITY NUMBER: 414004132
VISIT DATE: 11/18/2021
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LPA requests the following prior to approval:
  • An updated Facility Sketch for room P16 which reflects how the room will look once furnished and includes the location of the bathroom.
  • An updated overall sketch of whole facility which includes where room P16 is located on campus.
  • Pictures of room P16 once the room has been fully furnished.


No deficiencies cited today under CCR, Title 22, Div. 12, Ch. 1.

Report was reviewed and discussed with Director Carol Thomsen. A copy of report was provided.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC809 (FAS) - (06/04)
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